ICRs Contained in 45 CFR Part 162; HIPAA Standards for Electronic Transactions

X092A1

ICRs Contained in 45 CFR Part 162; HIPAA Standards for Electronic Transactions

OMB: 0938-0866

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2013-03-29 - Reinstatement without change of a previously approved collection

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ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X092A1 • 270/271
HEALTH CARE ELIGIBILITY BENEFIT INQUIRY AND RESPONSE

National Electronic Data Interchange
Transaction Set Implementation Guide

A
D
D
E
N
D
A

Health Care
Eligibility Benefit
Inquiry and
Response
270/271
ASC X12N 270/271 (004010X092A1)

October 2002
OCTOBER 2002

004010X092A1 • 270/271
HEALTH CARE ELIGIBILITY BENEFIT INQUIRY AND RESPONSE

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

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Copyright for the members of ASC X12N by Washington Publishing Company.
Permission is hereby granted to any organization to copy and distribute this material internally as long as this copyright statement is
included, the contents are not changed, and the copies are not sold.

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X092A1 • 270/271
HEALTH CARE ELIGIBILITY BENEFIT INQUIRY AND RESPONSE

Table of Contents
Introduction .................................................................................................. 5
Modified pages............................................................................................ 7

OCTOBER 2002

004010X092A1 • 270/271
HEALTH CARE ELIGIBILITY BENEFIT INQUIRY AND RESPONSE

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X092A1 270/271
HEALTH CARE ELIGIBILITY BENEFIT INQUIRY AND RESPONSE

1 Introduction to Modified Pages
This document is addenda to the X12N Health Care Eligibility Benefit Inquiry and
Response Implementation Guide, originally published May 2000 as 004010X092.
As a result of the post publication review process, items were identified that could
be considered impediments to implementation. These items were passed to the
X12N Health Care Work Group that created the original Implementation Guide
for their review.
Modifications based on those comments were reflected in a draft version of the
Addenda to the X12N 004010X092 Implementation Guide. Since the X12N
004010X092 Implementation Guide is named for use under the Health Insurance
Portability and Accountability Act of 1996 (HIPAA), an NPRM Draft Addenda went
through a Notice of Proposed Rule Making (NPRM) comment process that began
on May 31, 2002. Only the modifications noted in the NPRM Draft Addenda were
considered in the NPRM and X12N review processes. No changes to the Addenda were necessary based on comments received during the NPRM process
and X12N’s own review processes. The Addenda was approved for publication
by X12N on October 10, 2002. When using the X12N Health Care Eligibility Benefit Inquiry and Response Implementation Guide, originally published May 2000 as
004010X092 and incorporating the changes identified in the Addenda, the value
used in GS08 must be “004010X092A1".
Each of the changes made to the 004010X092 Implementation Guide has been
annotated with a note in red and a line pointing to the location of the change. For
convenience, the affected 004010X092 Implementation Guide page number is
noted at the bottom of the page. Please note that as a result of insertion or deletion of material Addenda pages may not begin or end at the same place as the
original referenced page. Because of this, Addenda pages are not page for page
replacements and the original pages should be retained.
Changes in the Addenda may have caused changes to the Data Element Dictionary and the Data Element Name Index (Appendix E in the original Implementation Guide), but these changes are not identified in the Addenda. Changes in the
Addenda may also have caused changes to the Examples and the EDI Transmission Examples (Section 4 in the original Implementation Guide), again these are
not identified in the Addenda.

OCTOBER 2002

004010X092A1 270/271
HEALTH CARE ELIGIBILITY BENEFIT INQUIRY AND RESPONSE

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X092A1 • 270 • 2100B • NM1
INFORMATION RECEIVER NAME

INFORMATION
004010X092A1 RECEIVER
NAME
• 270 • 2100B
• NM1

REQUIRED
JULY
19, 2001

NM108

Identification Code Qualifier

1/2

Code designating the system/method of code structure used for Identification
Code (67)
SYNTAX:

P0809

Use this element to qualify the identification number submitted in
NM109. This is the number that the information source associates
with the information receiver. Because only one number can be
submitted in NM109, the following hierarchy must be used.
Additional identifiers are to be placed in the REF segment. If the
information receiver is a provider and the National Provider ID is
mandated for use, code value “XX” must be used. Otherwise, one
of the following codes may be used with the following hierarchy
applied: Use the first code that applies: “SV”, “PP”, “FI”, “34". The
code ”SV" is recommended to be used prior to the mandated use of
the National Provider ID. If the information receiver is a payer and
the HCFA National PlanID is mandated for use, code value “XV”
must be used, otherwise, use code value “PI”. If the information
receiver is an employer, use code value “24".

1121

CODE

DEFINITION

Employer’s Identification Number
Use this code only when the 270/271 transaction
sets are used by an employer inquiring about
eligibility and benefits of their employees.

1123

Social Security Number
The social security number may not be used for any
Federally administered programs such as Medicare.

1199
FI

Federal Taxpayer’s Identification Number

Payor Identification
Use this code only when the 270/271 transaction
sets are used between two payers.

1124
PP

Pharmacy Processor Number

Service Provider Number
Use this code for the identification number assigned
by the information source to be used by the
information receiver in health care transactions.

1200
New code value

Health Care Financing Administration National
PlanID
Required if the National PlanID is mandated for use.
Otherwise, one of the other listed codes may be
used.
CODE SOURCE 540: Health Care Financing Administration
National PlanID

1000089
OCTOBER 2002

Health Care Financing Administration National
Provider Identifier
Required value if the National Provider ID is
mandated for use. Otherwise, one of the other listed
codes may be used.
See code source 537.

Original Page Number 52 dated May 2000

004010X092A1 • 270 • 2110C • EQ
SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY INFORMATION

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X092A1ELIGIBILITY
SUBSCRIBER
OR•BENEFIT
EQ
INQUIRY INFORMATION
• 270 • 2110C

New code value

National Drug Code in 5-4-2 Format
CODE SOURCE 240:

Code value ND deleted

National Drug Code by Format

Mutually Defined
NOT ADVISED
Use this code only for local codes or interim uses
until an appropriate new code is approved.

1071
REQUIRED

EQ02 - 2

234

Product/Service ID

1/48

Identifying number for a product or service
INDUSTRY: Procedure

Use this number for the product/service ID as identified by
the preceding data element (EQ02-1).

1131
SITUATIONAL

Code

EQ02 - 3

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the
service, as defined by trading partners

Used when an information source supports or may be
thought to support this high level of functionality if
modifiers are required to further specify the service. If not
supported, information source will process without this
data element.

1268

SITUATIONAL

EQ02 - 4

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the
service, as defined by trading partners

1268

SITUATIONAL

EQ02 - 5

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the
service, as defined by trading partners

1268

SITUATIONAL

EQ02 - 6

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the
service, as defined by trading partners

1268

NOT USED

EQ02 - 7

352

8 Original Page Number 96 dated May 2000

Description

1/80

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X092A1 • 270 • 2110D • EQ
DEPENDENT ELIGIBILITY OR BENEFIT INQUIRY INFORMATION

004010X092A1ELIGIBILITY
DEPENDENT
OR •BENEFIT
EQ
INQUIRY INFORMATION
• 270 • 2110D

New code value

Code value ND deleted

National Drug Code in 5-4-2 Format
CODE SOURCE 240:

National Drug Code by Format

Mutually Defined
NOT ADVISED
Use this code only for local codes or interim uses
until an appropriate new code is approved.

1071
REQUIRED

EQ02 - 2

234

Product/Service ID

1/48

Identifying number for a product or service
INDUSTRY: Procedure

Use this number for the product/service ID as identified by
the preceding data element (EQ02-1).

1131
SITUATIONAL

Code

EQ02 - 3

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the
service, as defined by trading partners

1297

SITUATIONAL

EQ02 - 4

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the
service, as defined by trading partners

1297

SITUATIONAL

EQ02 - 5

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the
service, as defined by trading partners

1297

SITUATIONAL

EQ02 - 6

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the
service, as defined by trading partners

1297

NOT USED

OCTOBER 2002

EQ02 - 7

352

Description

1/80

Original Page Number 138 dated May 2000

004010X092A1 • 271 • 2100C • REF
SUBSCRIBER ADDITIONAL IDENTIFICATION

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X092A1ADDITIONAL
SUBSCRIBER
IDENTIFICATION
• 271 • 2100C
• REF

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

REF01

DATA
ELEMENT

128

NAME

ATTRIBUTES

Reference Identification Qualifier

2/3

Code qualifying the Reference Identification

Use this code to specify or qualify the type of reference number
that is following in REF02, REF03, or both.

1023

CODE

DEFINITION

Plan Number

Group or Policy Number
Use this code only if it cannot be determined if the
number is a Group Number or a Policy number. Use
codes IG or 6P when they can be determined.

1232

Member Identification Number
Use only if Loop 2100C NM108 contains ZZ, and is
prior to the mandated use of the HIPAA Unique
Patient Identifier.

1363

Case Number

Family Unit Number
This is the Suffix to the Subscriber’s Member
Identification Number, which allows the information
source to use one identification number as the base
number for each family member. The suffix
identifies the individual family member. Only the
suffix is to be entered here. The Member
Identification Number is to be entered in Loop 2100C
NM109 or REF02. If the complete Member
Identification Number with the suffix is entered in
Loop 2100C NM109 or REF02, the suffix should not
be entered here.

1233

New code value

Group Number

Employee Identification Number

Contract Number
This code is to be used only to identify the
provider’s contract number of the provider identified
in the PRV segment of Loop 2100C. This code is
only to be used once the HCFA National Provider
Identifier has been mandated for use, and must be
sent if required in the contract between the
Information Receiver identified in Loop 2100B and
the Information Source identified in Loop 2100A.

1233

Medical Record Identification Number

Patient Account Number

10 Original Page Number 197 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X092A1 • 271 • 2110C • EB
SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION

004010X092A1ELIGIBILITY
SUBSCRIBER
OR•BENEFIT
EB
INFORMATION
• 271 • 2110C

REQUIRED

EB13 - 1

235

Product/Service ID Qualifier

2/2

Code identifying the type/source of the descriptive number used in
Product/Service ID (234)
INDUSTRY: Product

or Service ID Qualifier

Use this code to identify the external code list of the
following procedure/service code.

1043

CODE

DEFINITION

American Dental Association Codes
CODE SOURCE 135:

Current Procedural Terminology (CPT) Codes
CODE SOURCE 133:

American Dental Association Codes

Current Procedural Terminology (CPT) Codes

Health Care Financing Administration Common
Procedural Coding System (HCPCS) Codes
CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System

International Classification of Diseases Clinical
Modification (ICD-9-CM) - Procedure
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure

New code values

1091

Code value ND
deleted

Home Infusion EDI Coalition (HIEC) Product/Service
Code
This code set is not allowed for use under HIPAA at
the time of this writing. The qualifier can only be
used 1) If a new rule names HIEC as an allowable
code set under HIPAA. 2) For Property & Casualty
claims/encounters that are not covered under
HIPAA.
CODE SOURCE 513: Home Infusion EDI Coalition (HIEC)
Product/Service Code List

National Drug Code in 5-4-2 Format
CODE SOURCE 240:

National Drug Code by Format

Mutually Defined
NOT ADVISED
Use this code only for local codes or interim uses
until an appropriate new code is approved.

1091
REQUIRED

EB13 - 2

234

Product/Service ID

1/48

Identifying number for a product or service
INDUSTRY: Procedure

Use this ID number for the product/service code as qualified
by the preceding data element.

1052
SITUATIONAL

Code

EB13 - 3

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the
service, as defined by trading partners

1407

OCTOBER 2002

Use this modifier for the procedure code identified in EB132 if modifiers are needed to further specify the service.

Original Page Number 231 dated May 2000

004010X092A1 • 271 • 2120C • PRV
SUBSCRIBER BENEFIT RELATED PROVIDER IDENTIFICATION

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X092A1BENEFIT
SUBSCRIBER
RELATED
PROVIDER IDENTIFICATION
• 271 • 2120C
• PRV

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

PRV01

DATA
ELEMENT

1221

NAME

ATTRIBUTES

Provider Code

1/3

Code indentifying the type of provider
CODE

New code values

DEFINITION

Admitting

Attending

Billing

Consulting

Covering

Hospital

Home Health Care

Laboratory

Other Physician

Pharmacist

Pharmacy

Primary Care Physician

Performing

Rural Health Clinic

Referring

Submitting

Skilled Nursing Facility

Supervising

Original Page Number 262 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X092A1 • 271 • 2100D • REF
DEPENDENT ADDITIONAL INFORMATION

004010X092A1ADDITIONAL
DEPENDENT
INFORMATION
• 271 • 2100D
• REF

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

REF01

DATA
ELEMENT

128

NAME

ATTRIBUTES

Reference Identification Qualifier

2/3

Code qualifying the Reference Identification

Use this code to specify or qualify the type of reference number
that is following in REF02, REF03, or both.

1023

CODE

Plan Number

Group or Policy Number
Use this code only if it cannot be determined if the
number is a Group Number or a Policy number. Use
codes “IG” or “6P” when they can be determined.

1244

Family Unit Number
This is the suffix to the Dependent’s Member
Identification Number which allows the information
source to use one identification number as the base
number for each family member. The suffix
identifies the individual family member. Only the
suffix is to be entered here. The Member
Identification Number is to be entered in Loop 2100C
NM109 or REF02. If the complete Member
Identification Number with the suffix is entered in
Loop 2100D NM109 or REF02, the suffix should not
be entered here.

1239

New code values

Group Number

Employee Identification Number

Contract Number

Medical Record Identification Number

Patient Account Number

OCTOBER 2002

Member Identification Number
Use only if Loop 2100D NM108 contains ZZ, and is
prior to the mandated use of the HIPAA Unique
Patient Identifier.

1369

1266

DEFINITION

Health Insurance Claim (HIC) Number
See segment note 2.

Original Page Number 275 dated May 2000

004010X092A1 • 271 • 2110D • EB
DEPENDENT ELIGIBILITY OR BENEFIT INFORMATION

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X092A1ELIGIBILITY
DEPENDENT
OR •BENEFIT
EB
INFORMATION
• 271 • 2110D

Current Procedural Terminology (CPT) Codes
CODE SOURCE 133:

Current Procedural Terminology (CPT) Codes

Health Care Financing Administration Common
Procedural Coding System (HCPCS) Codes
CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System

International Classification of Diseases Clinical
Modification (ICD-9-CM) - Procedure
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure

New code values

1091

Home Infusion EDI Coalition (HIEC) Product/Service
Code

Code value ND
deleted

This code set is not allowed for use under HIPAA at
the time of this writing. The qualifier can only be
used 1) If a new rule names HIEC as an allowable
code set under HIPAA. 2) For Property & Casualty
claims/encounters that are not covered under
HIPAA.
CODE SOURCE 513: Home Infusion EDI Coalition (HIEC)
Product/Service Code List

National Drug Code in 5-4-2 Format
CODE SOURCE 240:

National Drug Code by Format

Mutually Defined
NOT ADVISED
Use this code only for local codes or interim uses
until an appropriate new code is approved.

1091
REQUIRED

EB13 - 2

234

Product/Service ID

1/48

Identifying number for a product or service
INDUSTRY: Procedure

Use this ID number for the product/service code as qualified
by the preceding data element.

1052
SITUATIONAL

Code

EB13 - 3

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the
service, as defined by trading partners

Use this modifier for the procedure code identified in EB132 if modifiers are needed to further specify the service.

1443
SITUATIONAL

EB13 - 4

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the
service, as defined by trading partners

Use this modifier for the procedure code identified in EB132 if modifiers are needed to further specify the service.

1443
SITUATIONAL

EB13 - 5

1339

Procedure Modifier

2/2

This identifies special circumstances related to the performance of the
service, as defined by trading partners

1443

Use this modifier for the procedure code identified in EB132 if modifiers are needed to further specify the service.

14 Original Page Number 308 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X092A1 • 271 • 2120D • PRV
DEPENDENT BENEFIT RELATED PROVIDER INFORMATION

004010X092A1BENEFIT
DEPENDENT
RELATED
PROVIDER INFORMATION
• 271 • 2120D
• PRV

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

PRV01

DATA
ELEMENT

1221

NAME

ATTRIBUTES

Provider Code

1/3

Code indentifying the type of provider
CODE

New code values

OCTOBER 2002

DEFINITION

Admitting

Attending

Billing

Consulting

Covering

Hospital

Home Health Care

Laboratory

Other Physician

Pharmacist

Pharmacy

Primary Care Physician

Performing

Rural Health Clinic

Referring

Submitting

Skilled Nursing Facility

Supervising

Original Page Number 338 dated May 2000

004010X092A1 • 270/271
HEALTH CARE ELIGIBILITY BENEFIT INQUIRY AND RESPONSE

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

Data elements are assigned a unique reference number. Each data element has
a name, description, type, minimum length, and maximum length. For ID type
data elements, this guide provides the applicable ASC X12 code values and their
descriptions or references where the valid code list can be obtained.
Each data element is assigned a minimum and maximum length. The length of
the data element value is the number of character positions used except as
noted for numeric, decimal, and binary elements.
The data element types shown in matrix A4, Data Element Types, appear in this
implementation guide.
SYMBOL
TYPE
Nn
Numeric
R
Decimal
ID
Identifier
AN
String
DT
Date
TM
Time
B
Binary
Matrix A4. Data Element Types

A.1.3.1.1

Numeric
A numeric data element is represented by one or more digits with an optional
leading sign representing a value in the normal base of 10. The value of a numeric data element includes an implied decimal point. It is used when the position of the decimal point within the data is permanently fixed and is not to be
transmitted with the data.
This set of guides denotes the number of implied decimal positions. The representation for this data element type is “Nn” where N indicates that it is numeric
and n indicates the number of decimal positions to the right of the implied decimal point.
If n is 0, it need not appear in the specification; N is equivalent to N0. For negative values, the leading minus sign (-) is used. Absence of a sign indicates a positive value. The plus sign (+) should not be transmitted.
EXAMPLE
A transmitted value of 1234, when specified as numeric type N2, represents a
value of 12.34.
Leading zeros should be suppressed unless necessary to satisfy a minimum
length requirement. The length of a numeric type data element does not include
the optional sign.

A.1.3.1.2

Decimal
A decimal data element may contain an explicit decimal point and is used for numeric values that have a varying number of decimal positions. This data element
type is represented as “R.”
The decimal point always appears in the character stream if the decimal point is
at any place other than the right end. If the value is an integer (decimal point at
the right end) the decimal point should be omitted. For negative values, the leading minus sign (-) is used. Absence of a sign indicates a positive value. The plus
sign (+) should not be transmitted.

Original Page Number A.5 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X092A1 • 270/271
HEALTH CARE ELIGIBILITY BENEFIT INQUIRY AND RESPONSE

Leading zeros should be suppressed unless necessary to satisfy a minimum
length requirement. Trailing zeros following the decimal point should be suppressed unless necessary to indicate precision. The use of triad separators (for
example, the commas in 1,000,000) is expressly prohibited. The length of a decimal type data element does not include the optional leading sign or decimal point.
EXAMPLE
A transmitted value of 12.34 represents a decimal value of 12.34.
New note

For implementation of this guide under the rules promulgated under the Health Insurance Portability and Accountability Act (HIPAA), decimal data elements in
Data Element 782 (Monetary Amount) will be limited to a maximum length of 10
characters including reported or implied places for cents (implied value of 00 after
the decimal point). Note the statement in the preceding paragraph that the decimal point and leading sign, if sent, are not part of the character count.

A.1.3.1.3

Identifier
An identifier data element always contains a value from a predefined list of codes
that is maintained by the ASC X12 Committee or some other body recognized by
the Committee. Trailing spaces should be suppressed unless they are necessary
to satisfy a minimum length. An identifier is always left justified. The representation for this data element type is “ID.”

A.1.3.1.4

String
A string data element is a sequence of any characters from the basic or extended
character sets. The significant characters shall be left justified. Leading spaces,
when they occur, are presumed to be significant characters. Trailing spaces
should be suppressed unless they are necessary to satisfy a minimum length.
The representation for this data element type is “AN.”

A.1.3.1.5

Date
A date data element is used to express the standard date in either YYMMDD or
CCYYMMDD format in which CC is the first two digits of the calendar year, YY is
the last two digits of the calendar year, MM is the month (01 to 12), and DD is the
day in the month (01 to 31). The representation for this data element type is “DT.”
Users of this guide should note that all dates within transactions are 8-character
dates (millennium compliant) in the format CCYYMMDD. The only date data element that is in format YYMMDD is the Interchange Date data element in the ISA
segment, and also used in the TA1 Interchange Acknowledgment, where the century can be readily interpolated because of the nature of an interchange header.

A.1.3.1.6

Time
A time data element is used to express the ISO standard time HHMMSSd..d format in which HH is the hour for a 24 hour clock (00 to 23), MM is the minute (00
to 59), SS is the second (00 to 59) and d..d is decimal seconds. The representation for this data element type is “TM.” The length of the data element determines the format of the transmitted time.
EXAMPLE
Transmitted data elements of four characters denote HHMM. Transmitted data
elements of six characters denote HHMMSS.

OCTOBER 2002

Original Page Number A.6 dated May 2000

004010X092A1 • 270/271 • GS
FUNCTIONAL GROUP HEADER
FUNCTIONAL GROUP HEADER
GS

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X092A1GROUP
FUNCTIONAL
GS
• 002 • HEADER

IMPLEMENTATION

FUNCTIONAL GROUP HEADER
Example: GS✽HB✽SENDER CODE✽RECEIVER
CODE✽19971001✽0802✽1✽X✽004010X092A1~

005
100
4

Changed example

STANDARD

GS Functional Group Header
Purpose: To indicate the beginning of a functional group and to provide control information
DIAGRAM

GS01

GS ✽

479

Functional
ID Code
M

GS07

GS02

2/2

455

GS08

✽ Responsible ✽
Agency Code
M

1/2

142

GS03

✽ Application ✽
Send’s Code
AN 2/15

AN 2/15

GS04

373

Date

✽
M

GS05

✽
8/8

337

Time
M

GS06

✽
4/8

Group Ctrl
Number
M

1/9

480

Ver/Release
ID Code
M

124

Application
Rec’s Code

AN 1/12

ELEMENT SUMMARY

USAGE

REQUIRED

REF.
DES.

GS01

DATA
ELEMENT

479

NAME

ATTRIBUTES

Functional Identifier Code

2/2

Code identifying a group of application related transaction sets
CODE

REQUIRED

GS02

142

DEFINITION

Eligibility, Coverage or Benefit Information (271)

Eligibility, Coverage or Benefit Inquiry (270)

Application Sender’s Code

2/15

Code identifying party sending transmission; codes agreed to by trading partners

Use this code to identify the unit sending the information.

1000009
REQUIRED

GS03

124

Application Receiver’s Code

2/15

Code identifying party receiving transmission. Codes agreed to by trading partners

Use this code to identify the unit receiving the information.

1000010
REQUIRED

GS04

373

Date

8/8

Date expressed as CCYYMMDD
SEMANTIC:

1000011

GS04 is the group date.

Use this date for the functional group creation date.

Original Page Number B.8 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

REQUIRED

GS05

337

004010X092A1 • 270/271 • GS
FUNCTIONAL GROUP HEADER

Time

4/8

Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or
HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S =
integer seconds (00-59) and DD = decimal seconds; decimal seconds are
expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
SEMANTIC:

Use this time for the creation time. The recommended format is
HHMM.

1000012
REQUIRED

GS05 is the group time.

GS06

Group Control Number

1/9

Assigned number originated and maintained by the sender
The data interchange control number GS06 in this header must be
identical to the same data element in the associated functional group trailer,
GE02.

SEMANTIC:

REQUIRED

GS07

455

Responsible Agency Code

1/2

Code used in conjunction with Data Element 480 to identify the issuer of the
standard
CODE

X
REQUIRED

GS08

480

DEFINITION

Accredited Standards Committee X12

Version / Release / Industry Identifier Code

1/12

Code indicating the version, release, subrelease, and industry identifier of the EDI
standard being used, including the GS and GE segments; if code in DE455 in GS
segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6
are the release and subrelease, level of the version; and positions 7-12 are the
industry or trade association identifiers (optionally assigned by user); if code in
DE455 in GS segment is T, then other formats are allowed
CODE

New code value

1091

OCTOBER 2002

DEFINITION

004010X092A1 Draft Standards Approved for Publication by ASC
X12 Procedures Review Board through October
1997, as published in this implementation guide.
When using the X12N Health Care Eligibility Benefit
Inquiry and Response Implementation Guide,
originally published May 2000 as 004010X092 and
incorporating the changes identified in the Addenda,
the value used in GS08 must be “004010X092A1".

Original Page Number B.9 dated May 2000

004010X092A1
HEALTH CARE ELIGIBILITY BENEFIT INQUIRY AND RESPONSE

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

HEALTH CARE ELIGIBILITY BENEFIT INQUIRY AND RESPONSE
004010X092A1

OCTOBER 2002

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File Modified	2002-10-31
File Created	2001-09-28